Working Hard and Being Successful

I've been reading about and discussing socioeconomic barriers to success lately, particularly as it relates to medicine. I also had an opportunity to be a very small part of an outreach program aimed at increasing interest in medicine in youth from disadvantaged backgrounds. One aspect to socioeconomic disadvantage I've found myself increasingly reflecting on is how multifaceted and variable this disadvantage can be. Thinking back, I've found most conversations on socioeconomic disadvantage tend to treat it as more uniform or monolithic than it is, and I've fallen into that trap of thinking too often as well. Perhaps others have come to this realization and I'm just behind in the thought-process, but I'd like to take a post to spell things out a little bit for my own sake.

To be perhaps a bit over-simplistic, I see a few distinct ways in which low socioeconomic status can manifest itself into real barriers to achievement. First is a simple lack of resources, which tends to be the focus of many interventions to assist those from lower socioeconomic backgrounds. It's undoubtedly a major problem - if some people can pay for things that others can't, and those things either directly or indirectly lead to personal achievement, then wealthier individuals will naturally benefit over their less-wealthy counterparts. In medicine these lead to some obvious and not-so-obvious barriers. To get into medicine, a student needs to pay for their undergraduate education, the MCAT, application fees, travel to interviews, and interview attire. These are not small expenses, especially when added together. However, that's just the bare minimum. Things money can buy that aren't necessary, but very helpful for getting into medical school include taking extra courses or second degrees (or even doing medical school outside of Canada), taking various prep courses or receiving extra tutoring, spending more time on unpaid extra-curriculars, or even paying for certain extra-curriculars.

Yet these examples hit only the "economic" portion of socioeconomic status. To get into medical school, there is also a significant social component that I don't believe gets recognized as often as it perhaps should. One is the development of baseline skills that many people take for granted. To use an extreme example, if a person was never taught how to read, they won't get into medical school, no matter how intelligent, responsible, and personable they might be. They can, of course, learn how to read and then start to move towards medicine, but it's a difficult skill to learn in adulthood and fundamental to all the steps that come after it. It's also a skill that typically requires significant support from others. We're lucky that in Canada most people get that support as children, but there are other skills which are not provided as reliably by our primary or secondary education system. One that springs to mind is professional communication skills, which are sorely lacking in formal education. The ability to write a concise, polite, effective e-mail has enormous benefits in securing various opportunities on a path to medicine, yet this may not be a skill some individuals even see from their elders or peers if they grow up in a setting without business people or other professionals in their lives. It's a skill that can be developed, but this takes time, support, and a certain degree of trial-and-error that more initiated individuals will not have to go through.

Likewise, access to opportunities is far from equitable across individuals of different social status. One example that comes to mind is students who happen to have physicians as parents. These parents hear about or inquire about opportunities with their colleagues and provide a point of introduction for their children. These students must still show they are worthy of those opportunities and perform well once they secure them to advance further, but that first step is often a critical one. More importantly, opportunities create a snowball effect, where prior experience justifies acceptance to future opportunities, up to and including medical school. That is, individuals with higher social status and more connections can turn into seemingly more capable applicants - and may actually be more capable applicants - due to these connections, completely unrelated to ability or effort.

I'd like to emphasize that higher socioeconomic status does not remove the need for hard work or eliminate the role of a certain degree of natural ability in the process. Medicine, like many fields, is full of well-off individuals, but these people have nevertheless put in significant effort to get to where they are. However, what my recent experiences have reminded me of is that while hard work is necessary for success, it is not sufficient on its own, hence the title of this piece. Without trying to set up too much of a strawman, I think some well-off individuals give too much credit to their own hard work in achieving success, because they started to see success when they started putting in the effort. Yet these individuals started seeing success after they started to work harder towards success because everything else was already set up for them. I've met plenty of people who haven't had the same experience, where hard work perhaps improved their situations, but that improvement was limited due to factors beyond their control.

Bringing this back to the original point about the multifaceted nature of socioeconomic disadvantage for a minute, I now worry more that many interventions to improve such disadvantage are perhaps too simplistic to be effective. We can throw money at a problem but it can end up being a waste if the more social aspects to disadvantage are left unaddressed. On the flip side, we could try to improve these social elements, yet see minimal results if resources are still lacking. However, on a more positive note, this also means that there are many different ways we can make marginal improvements in peoples' lives. If we don't have money to help, we can volunteer time to teach new skills, or provide connections that might otherwise being lacking. If we're busy and running off our feet, financial supports can nevertheless be valuable. When people move up the socioeconomic ladder, patchwork systems of support like this can be an important reason why, allowing them to fully utilize their own natural talents and work ethic.

From a personal perspective, as I move forward within my own career in medicine, I'm hoping there will be more opportunities to level the playing field a little bit - and I hope I'll have the good sense to recognize when those opportunities arise.

Exam Studying

I'm in the middle of studying for my neurology exam right now... not a fun time. What's really weird about this exam is that there are some elements I feel like I know implicitly, without ever having studied them, while some subjects I'm not only struggling to learn, I'm struggling with how to learn them.

Learning in medicine is a lot like putting together a giant puzzle. Except, you don't know what the puzzle looks like. Or even it's shape. Or size.

When you learn a new fact in medicine, it's like getting an additional puzzle piece that you're expected to put into your puzzle. Except you don't really know the colour of your piece (or at best, you have a vague idea). It's shape also starts out a bit fuzzy - you don't really know what other pieces that piece connects to. This makes it very difficult to know where to place it, so you guess and hope it's in the right spot.

Over time, as the facts you learn once get repeated, the pieces become a bit clearer. The second time a fact is mentioned, maybe the colour comes into focus a bit better. The third time, an edge stands out clearly. The fourth time, another edge pops more plainly into view. With each repetition, it becomes more obvious where the piece should fit.

Neurology is hitting both ends of the spectrum for me. Cranial nerves I feel like I know, without ever having really studied them. They were introduced in my first year, several times. They've now been introduced again, in my second year, several times. I've never really sat down and studied them, but I also don't feel like I have to.

On the other end, I'm struggling with headaches (the topic, not me having headaches - though that second part may come in time). Headaches have really only been introduced once in my two years. I'm studying the material as best I can, looking for additional resources and trying to figure out all the details, but I don't feel like I have a good grasp of even the basics of headaches.

It really makes me wish more topics were taught like cranial nerves at my school - repeated instances, separated in time and in slightly different contexts. I know that I have to study and not everything can be adequately taught in school, but the divide in confidence I have in understanding these two subjects really strikes me. I'd love to see a lot more longitudinal learning with repetition of material than we currently receive.

Talent

Every year, our school puts on a bit of a variety show, with each class contributing a decent-length skit to the show. I've not have had the pleasure of being involved due to lack of time and more importantly, complete lack of talent.

However, I got to see the finished product this year and it was nothing short of incredible. I don't have much talent for singing, dancing, acting, or theatrical production, but wow, my classmates certainly do. I get impressed on a reasonably regular basis at the medicine-related strengths of my fellow medical students - it's great to be reminded not only that they're capable future physicians, but capable people in general.

They put on a highly entertaining show with fairly strong production values, all the proceeds went to a deserving charity, and all those involved are going to be showing up for class on Monday to get back at it with the rest of us. Seeing their talent on display was both humbling and motivating - I like to think I work hard and do what I do well (I believe that's mostly true), but it's too easy to neglect the hard work and competence of others. It was on full display at last night's show.

Team-Based Learning

Over the course of my too-many years of undergraduate education, I've had multiple opportunities to engage in team-based learning (TBL). TBL is exactly what it sounds like - learning in teams. The basic premise is that students know more collectively than they do individually and pooling that knowledge in a team setting allows it to be disseminated between students within that team more effectively than a traditional lecture format or with a self-study approach.

I've seen this used to good effect (my most recent interaction with TBL was quite positive), but in more instances, my experiences with TBL have been frustrating or unhelpful.

Like any approach to education, TBL is a tool, one which is appropriate in some situations, but not so appropriate in others. You wouldn't use a screwdriver to hammer in a nail; likewise, TBL shouldn't be used indiscriminately. That's no knock against TBL - just like screwdrivers are great for putting in screws, TBL is great when used where it's most effective.

TBL has greatest value in application problems. To answer these questions, details need to be shared between participants. If there are any differences in interpretations of core concepts, they also need to be contrasted or discussed to come to a solution. A single person knowing a detail leads to everyone knowing it within the team while interpretations of concepts can be refined and disseminated among group participants.

Where TBL falters is in the introduction of new information, or the regurgitation of facts without application. No matter how big a group is, if no one within that group knows a piece of information, it won't get shared. Data needs to come from somewhere, so TBL cannot be used as a substitute for teaching core concepts or fundamental data. A shared framework is necessary for TBL to work. Likewise, using TBL to test simple knowledge retention is fairly inefficient. There's no impetus for discussion - either group members know a fact or they don't, so deciding on the "correct" answer to a question often comes down to a matter of democracy (the most popular answer wins) or confidence (the most assured person's answer wins). There's no real value to collaboration in this case.

TBL was primarily introduced into physics instruction, where it works quite well. Physics is a conceptually challenging field, where the primary difficult comes from application of concepts rather than memorization of those concepts. Since it has worked rather well in a troublesome area of study, it has naturally received a fair bit of attention from educators.

However, as too often happens in education (and medicine), a good idea in one area has been applied in areas to which it is ill-suited. Medicine can be taught either in a wrote-memorization format, or through applications. The former is a poor fit for TBL. The latter works well for TBL. I've seen both. My hope is that, moving forward, medical educators try to be more discriminating about the use of TBL or at least adapt their TBL sessions to better take advantage of its virtues.

Match Day (well, not for me)

So, today was the CaRMS match day. Hundreds of graduating medical students just found out where they will spend the next 2-6+ years of their lives and what they'll be doing for the rest of their careers.

It's a day of very mixed emotions. For many, it's the best day of their lives. They get validation for 3-4+ years of hard work and learning. More importantly, they get a chance to help patients in the way they want to help patients, to have the career they wanted. Getting into medical school was a huge moment for me, but I'm not considering my career on track until I know my residency placement. I think a lot of students feel similarly, which is why getting a good result on Match Day is such a huge deal. It's a life-defining moment.

And yet, there are some who got less-than-stellar news today. There's always a percentage of people don't match each year in the first iteration. To them, it's a crushing moment, full of anxiety, fear, and uncertainty. Many will go through this whole process again with the unfilled spots left in the second iteration. By definition, these spots will be ones that had already rejected the unmatched applicants, or ones which those applicants chose not to apply to. That's a very tough pill to swallow - anything left that an applicant wants has basically already said "no", so they have to pursue programs they didn't want in the first place.

In the middle are people who matched, but went so far down their list of preferred programs that there's a major element of doubt. They'll be heading to a location or specialty they didn't fully expect to get, and have to make a major readjustment in mentality and life planning. That's a big curveball just when a career is starting to take off - and there's no backing out. CaRMS is a contract, so once you're matched, that's where you're going.

It's hard to know what to feel on days like today. Elation for some, cautious optimism for others, consolation for a few more.

Of course, being someone who will go through this all in a few short years, it's hard not to be a little scared of what's coming. Today's not about me - not even close - but it's tempting to put myself in the shoes of the current graduating class. To feel the unbridled excitement of matching to a first-choice program. To steel myself for the possibility that maybe I'll have to settle for a backup I never thought I'd end up with. To experience the dread of going unmatched and what I might do today to avoid that fate.

As I said - a day of mixed emotions.

Conference Time

I'm at a conference, getting ready to present some of the research I've done over the last year or so. I love presenting my work and hearing the work others have done. I've already had a chance to hear about some fairly interesting research being done across Canada - and I really hope people find my research worthwhile.

That said, I hate conferences. This one is held at a very nice village out in the middle of nowhere. I drove for 7+ hours to get here, not including breaks for food and sanity. The plumbing has been problematic and so we've lost water several times so far. And everything is crazy expensive.

It'd be a nice place to go for a vacation, not all that ideal for doing work which, of course, I still have plenty of.

Is there any way to do the exchange of ideas in a conference without conference-level expense or hassle?

Specialty Popularity

After my little rant about how specialty competitiveness has influenced my thinking on what specialties I want to pursue, I got to thinking about what makes specialties more of less desirable to students.

The short list of factors is fairly obvious:
- Clinical activities
- Academic interest
- Lifestyle
- Job availability
- Money
- Non-clinical activities (research, teaching, paperwork, etc.)

Desired clinical activities, non-clinical activities, and academic interest really depend on the individual, but the other three factors are a bit more universal. Most people want to get a job easily in a location they want, to be paid well, and to work less than what most physicians end up working.

Right now, the highly competitive specialties are Plastic Surgery, Dermatology, Emergency Medicine, and Ophthalmology. Dermatology hits all three of those universally-desired characteristics. It pays well, jobs are everywhere, and it has a reasonable lifestyle. Emergency Medicine pays less and shift work isn't for everyone, but it also has good job availability and low hours overall. Plastics pays well, plus it has a better job market and lifestyle than most surgical specialties (though probably worse on both fronts compared to non-surgical specialties). Ophthalmology is a bit of an outlier - terrible job market, but the work load isn't horrible and the pay is incredibly high.

So, those highly competitive specialties largely fit the mold.

When we look at the more moderately competitive specialties, however, things start to change. Many surgical specialties remain reasonable competitive despite a complete lack of desirable jobs and a frankly horrible lifestyle. The pay is pretty good, however. OBGYN is in somewhat the same boat, trading a slightly better lifestyle and job market for a slightly worse salary in most parts of the country. Radiology has good pay, but the lifestyle is not what it used to be and the job market has not been great in recent years. Pediatrics has reasonable job opportunities and lifestyle, but low relative salary. Anesthesiology is about the only moderately competitive specialty that has a good job market, good salary, and good lifestyle.

Contrast this with the minimally competitive specialties. Family and Psychiatry have plenty of jobs and pretty good lifestyles, but generally low compensation. Internal Medicine is a bit more mixed and highly dependent on subspecialty, but overall lifestyle is decent, the job market is alright, and compensation is average-to-low (subspecialties with higher pay tend to have poor job opportunities). There are also a few small fields with poor job opportunities, good lifestyles and variable pay.

Interestingly, the most predictive factor for determining specialty competitiveness seems to be money. Only pediatrics and emergency medicine really break the mold, being more competitive than their average compensation would suggest. Lifestyle and job opportunities seem to matter to the extent that specialties of roughly equal pay are more competitive when they have these elements, but the correlation is much weaker.

Of course, personal factors matter, as does the relative number of positions for each specialty. Surgery is cool! There may not be jobs in many surgical specialties and an overall poor lifestyle, but students still want to do it. On the flip side, family medicine may not be competitive, but it sure is popular - it's just in such high demand from patients that there's little fight for family medicine residencies. Likewise, emergency medicine may be competitive simply because the number of residency positions is needlessly low.

Anyway, apologies for the rant - just needed to spell those thoughts out in writing.

Educational Dogs

Most people have heard of therapy dogs for patients - I'd like to propose educational dogs for teaching. Our class has a number of people with dogs, myself included, and one of my classmates has a little dog that comes to class every once in a while.

It's great - the dog is very well behaved and provides a nice distraction without taking much away from the lecture. Plus, it's an adorable dog!

Anyway, we were in class this week and he started barking. First time I've heard this dog really bark. The lecturer could have gotten annoyed or upset at the dog for interrupting their class, or at their owner for bringing it, but instead, they immediately quipped "See, even he thinks [insert point lecturer was making] is important!"

The whole class laughed, everyone woke up a bit, and the lecture continued without missing a beat. That's how to do education right. Sometimes, in both education and medicine, we get too caught up with etiquette and proper procedure. Having a tiny dog running around the classroom is not proper procedure for a lecture. And yet, it was an improvement having him around.

We get too worried about not doing something wrong, that we forget to stick our necks out a bit to do something right, even if it's as inconsequential as having an educational dog.

It's That Match Time of the Year Again!

The CaRMS match day is approaching. I'm still a few years away from that, but since I've been compulsively planning for that day since even before I got my acceptance to Med School, it's still a day I take note of. This year I'll have actually worked a bit with some of the people in the match, so I've got my fingers crossed it turns out well for them.

More selfishly, I like to see the trends in the match statistics. Some specialties are getting more competitive, some less competitive. Which ones are and why can tell you a lot about where the medical field is going and how its perceived at the undergrad training level. More importantly, it can indicate what kind of competition I'll be facing for the specialties I'm interested in.

I realize this shouldn't matter - I'll do my best and if I get my first choice great, if not I'll be satisfied with my backups. However, the competitiveness of a specialty has, oddly, factored somewhat into my decision-making.

I'm very wary of pursuing overly competitive specialties. I'm an ambitious person, I work hard, and I'm not afraid to fight for a career path I want. However, I want that fight to against problems, not people. Highly competitive specialties attract highly competitive people. I like to think medicine is a collaborative enough enterprise that you don't see too much backstabbing or other sorts of power plays where one person wins and other people lose, but I know that it does happen and happens far more often when students are going for competitive specialties. More than that, there's a certain level of one-upmanship. Every time your competition does something noteworthy, you have to do something more noteworthy (or better yet, do noteworthy things first). That approach to a career is exhausting. Even beyond simply matching, when you're in a field with competitive people, the competition never stops. There's always a research position, a fellowship, a potential job opening to fight for. I've got enough pressure to do my best, both external pressure and internal pressure. I want to routinely push myself to my limits to be a productive, effective physician. But I do have limits and don't want others to push me beyond them. I've seen too many unhappy physicians who are working beyond their limits.

By the same token, I'm somewhat skeptical of completely uncompetitive specialties. I worry that there are reasons students avoid these specialties that I haven't considered. I worry that my colleagues in these specialties will be less competent than those in other specialties. I worry these specialties won't be challenging enough, won't be rewarding enough or, to my great shame, won't be prestigious enough.

As an aside, having a more prestigious job is like winning a pissing contest - you satisfy your ego, but it's ultimately meaningless. Yet, like so many medical students, I have an ego that just won't shut up, even when I'd like it to.

So, my first choice of specialty is currently one that is only moderately competitive. You have to do more than apply to get in, but no one seems to be throwing elbows to get matched to it either. Obviously there's more to my interest in this specialty than historical CaRMS match rates, but I do sometimes wonder how much of that interest is affected by rather superficial judgments like the specialty's CaRMS match rate.

Time Management

There's a lot going on a school right now - too much. All my ECs are ramping up their time demands, I've got a conference coming up (which I haven't prepared for yet), we just got through a bunch of preparatory test (fake tests not worth any marks), and the real tests are coming soon.

By the end of this week I need to write two essays, start/finish studying for a hefty anatomy test, prepare my talk for that upcoming conference, start preparations on a weekend-long educational session in the summer, schedule an evening session for one of my ECs, and get the ball rolling on a major initiative for another one of my ECs.

Oh, and I probably need a haircut...

It's going to be a fun week!